Marketplace Launches With High Expectations, Hiccups

Zoila Chaver, second from right, a member of the Texas Organizing Project, giving health care information to Dallas resident Graciela Garcia at Garcia's home on July 10, 2013.

Updated 5:15 p.m.:

Down in South Texas, health care providers are reporting an unusual problem with the federal marketplace: Many patients don’t have email addresses and, therefore, can’t sign up online.

The Brownsville Community Health Center had 50 people show up on Tuesday ready to sign up for health coverage — many even brought pay stubs and income documentation — but not a single one of them had an email address.

“If you don’t include an email address, they won’t let you through,” said Christela Gomez, the special projects coordinator and lead certification application counselor at the center. Although the center considered helping people sign up for an email account, Gomez said many weren’t comfortable with the idea because they did not have a computer to access the email address later. “Quite a few didn’t even know what an email address was,” she added.

The center’s certified application counselors helped the patients fill out paper applications, but they’ll have to wait for a written response from the federal government to find out whether additional documentation is needed or whether those applicants qualify for tax credits.

Some of the questions on the paper application were difficult for patients to answer, said Gomez. One man who came in to receive assistance finding health coverage currently works as a truck driver, she said. He earns 30 cents per mile, and his income can range from $50 to $100 a week.

“We didn’t really know how to fill in the income part with him,” she said, adding, “We kind of just wrote it in on the side, his situation.”

Paula Gomez, the executive director of the center, said her patients are mostly adults who are too young to qualify for Medicare. Although most of her patients have jobs, pay taxes and want to cooperate with the health care system, there are extenuating circumstances like language barriers that make it difficult.

“I’m sure there are pockets like ours all over the country,” Gomez said. She added that the federal government should be more flexible and consider the different situations people are facing across the country. “They think in terms of everything that’s going on in Washington, D.C., but they don’t look at the reality of the rest of the world in the United States,” she said.

Updated 4:20 p.m.:

Ongoing technical difficulties on the new federal health insurance marketplace’s website have created road blocks for Texans trying to sign up and review coverage options under the Affordable Care Act.

“We keep getting kicked off the network, but we’ve screened some patients,” said José Camacho, executive director of the Texas Association of Community Health Centers. “People, from what we can gather at the centers, are quite excited.”

Although Tuesday marks the beginning of a six-month enrollment period, Camacho said many Texans have already shown up at federally qualified health centers to receive assistance applying for coverage in the exchange. He described one woman who has a master's degree but recently started a job that doesn’t offer health benefits coming to Lone Star Circle of Care in Georgetown seeking help. Unfortunately, glitches on the federal website prevented the certified application counselors at the center from helping the woman create an account and begin exploring her health plan options.

“With any new product launch, there are going to be glitches as things unfold,” Marilyn Tavenner, a federal administrator for the Centers for Medicare and Medicaid Services, said on a media conference call. She said that 2.8 million people have visited the federal marketplace since midnight, and more than 81,000 calls have been placed to their call center. “This is Day 1 of a process. We’re in a marathon, not a sprint, and we need your help,” she added.

Although the federal marketplace will eventually be able to determine whether an applicant is eligible for state programs like Medicaid and the Children’s Health Insurance Program, the Texas Health and Human Services Commission, which oversees those programs, said the federal website isn’t yet able to send applicants’ information directly to those plans. The agency is encouraging people who think they may be eligible for those programs to apply directly on the state website, Your Texas Benefits.

“This federal glitch could lead to delays in children getting health coverage,” Dr. Kyle Janek, executive commissioner of HHSC, said in a statement. “We’ve let workers in our offices around the state know about this issue so they can make sure families have accurate information.”

Sixty-seven federally qualified health centers that are members of TACHC collectively received $10 million to provide outreach, in-reach and enrollment assistance. So far, they’ve trained 230 certified application counselors. Some centers, such as Su Clinica Familiar in Harlingen and Brownsville, recently received certification and will finish training additional counselors in the coming weeks.

After signing himself up on HealthCare.gov around 8:30 a.m. on Tuesday, Carl Dahlquist, a certified application counselor and the outreach and enrollment supervisor at the Gulf Coast Health Center in Port Arthur, couldn’t get back into the system.

“We had a lot more come in today than we’ve had in the last several weeks because today was Oct. 1,” said Dahlquist. While most people wanted some advice and literature to take home and consider, Dahlquist said he used old-fashioned pen and paper to determine the eligibility status of one man. Although the man didn't qualify for coverage in the federal marketplace, Dahlquist said he was eligible for Texas Medicaid’s program for the elderly and disabled. Ironically, Dahlquist said the state’s website was also down.

Updated 1:30 p.m.:

Celebrating Tuesday’s launch of the Affordable Care Act on Tuesday at the United Way of Greater Austin, health care reform proponents from 22 organizations said that the law supplies the tools to provide insurance to millions of Texans who don’t have coverage. But they also acknowledged that they are at the “beginning of a long road.”

Among those at the event, which also celebrated the expansion of a 211 call center run by Central Health, the Travis County public hospital district, was Katharine Howard, an Austin freelance writer who has dystonia — a neurological movement disorder.

When she lost her job in 2009, she also lost her health coverage.

“My body would start twisting up like a cork screw,” she said, explaining the impact of the disorder. She has had to pay out of pocket for botox and dopamine injections in her neck and shoulders. When she called United Way of Greater Austin’s 211 call center a couple of weeks ago, she was enrolled in a program that reduced the monthly cost of her prescriptions to $50 from $600. She’s also hopeful that she’ll now be able to find an affordable health plan in the federal health insurance marketplace.

“That’s why I’m excited about this opportunity in the open marketplace, because I can get health insurance and I can get the treatment I need,” said Howard.

United Way of Greater Austin’s call center, which is expanding to assist people looking for a health plan and usually gets 150 calls a day, received 350 calls Monday, said Rosie Mendoza, chairwoman of the Central Health board of managers. “I can imagine where that number will go after today, and I look forward to that,” she added.

The Rev. Leslie Smith II, chief executive officer and founder of the Houston-based nonprofit Change Happens!, which received a $785,000 federal navigator grant, said it is also celebrating the launch of a call center to help uninsured Texans find coverage.

“Instead of everybody having individual call centers, we came together and did one,” said Smith, explaining that the navigator grant recipients in Houston — which include the city of Houston, the Urban League of Houston, Change Happens! and Gateway to Care — are coordinating their efforts to help uninsured residents find coverage.

Risha Jones, the city of Houston’s deputy director of community health services, said the group has determined which areas in the 13-county region have the highest rates of uninsured, divided up those areas among 11 health care organizations, and developed “strike teams” to canvass the neighborhoods with Enroll America and hold community outreach events.

“We’re dividing up the pie, so we can increase capacity and infrastructure and best use our limited resources,” Jones said.

Although it did not receive a federal navigator grant, Central Health of Travis County has awarded United Way of Greater Austin $300,000 to coordinate educational outreach efforts with Foundation Communities, Austin Interfaith and the Latino Health Care Forum to help uninsured Texans in the greater Austin region find health coverage.

“We are at the beginning of a long road,” Mendoza said. “We need to build awareness of the marketplace,” and the other options available for uninsured residents that were previously denied coverage for pre-existing conditions or could not afford to purchase coverage.

Frank Rodriguez, founder of the Latino Health Care Forum, cited his personal health history as an example of the changes that have resulted from the Affordable Care Act. When he began looking for a new health plan a couple of years ago, Rodriguez was denied because of a “pre-existing condition.” He’d never had a stroke, heart disease, cancer or diabetes, but he had weighed 300 pounds and had a lap-band surgery to lose weight. As a result, insurance companies denied him coverage.

“This is the healthiest I’ve ever been in my life, because of this surgery,” he said. Despite the setbacks, Rodriguez said he received temporary coverage through the Pre-Existing Condition Insurance Plan set up under the Affordable Care Act to provide insurance for people like him who has been denied coverage. That coverage allowed him to receive an annual check-up, at which, the doctor discovered he had prostate cancer.

“It was an aggressive-growing cancer, so I’m still undergoing treatment, but I think that’s a pretty successful story for Obamacare,” said Rodriguez, “because my formulary would have been no insurance, equals no attention, equals a dead health care advocate.”

Rodriguez said his organization is making a calculated effort to reach Hispanics and other people in the eight Austin-area ZIP codes with the highest percent of residents without insurance. While some groups, like Enroll America, will go door to door to educate people on their options, he says his group’s plan is to reach people at events like an upcoming car show that is popular among Hispanics in the area. Because the Latino Health Care Forum did not receive a federal navigator grant, it is also relying on certified community health workers to help with educational outreach. It has trained 75 community health workers, also called promotoras, over the last year and a half to help educate people in the greater Austin community.

Original story:

The much-anticipated launch of the federal health insurance marketplace — intended to help Texans find health coverage to comply with the Affordable Care Act — got off to a rocky start on Tuesday. Despite early technical difficulties, proponents of the law remain optimistic that the marketplace will help uninsured Texans find health care coverage.

Although the federal website, HealthCare.gov, indicated that the marketplace was open, users experienced multiple errors trying to create accounts and begin exploring their health plan options. First, some users were sent to a landing page to wait until the website was less busy. While filling out the application, other users received a server error that prevented them from selecting and answering security questions, which were required to finish creating an account. For those who were able to answer the security questions, many still received error messages.

“If everybody goes and tries to look ... they’re going to crash the system,” Ken Janda, president and chief executive officer of Community Health Choice, said Monday night, prior to the marketplace launch. “We’ve already crashed the system several times when we had several people testing it.”

Federal officials say they are aware of the issues, which have been caused by a high volume of people trying to access the website, and are working to fix the website as soon as possible. Meanwhile, they emphasized that people seeking help could still use the LiveChat function, contact the call center or use the in-person assistance locator to find a local “navigator” trained to help people access the system.

“We are thrilled that over 1 million people visited HealthCare.gov in the last day," Erin Shields, a spokeswoman for the U.S. Department of Health and Human Services, said in an email. "There were five times more users on the Marketplace website this morning than have ever been on the Medicare.gov at one time."

Tuesday marks the first day in a six-month enrollment period. Even before indications that the website was overloaded, health care advocates urged people to take their time picking a plan. On average, Texans will have 54 health plans in the exchange to choose from; the number of options varies depending on the region. (Use the Tribune’s interactive quiz to determine your best options for complying with the insurance mandate.)

For example, Janda said that CHC offers three health plans — Bronze, Silver and Gold — that have a logical progression: As premiums go up, the co-payments go down. The challenge facing consumers will be weighing all of the different options, Janda said, emphasizing that there are 43 health plans to choose from in Houston, each with a different deductible, co-payment rates, co-insurance rates, covered benefits, network size and participating providers.

Although CHC’s Silver plan is tied with another plan for the highest premium rate in the Houston region, Janda said the overall cost of their plan might be a better deal for consumers when you add in the additional costs associated with health coverage. While some of the plans have deductibles as high as $6,000 and charge co-insurance rates for office visits, CHC’s Silver plan has no deductible and charges a set co-payment of $40 per office visit.

“Don’t just look at the lowest price plans out there,” he said. “You’ve really got to study the pricing before you just say, ‘Oh wow, this is really cheap.’”

Texas’ state leaders have consistently opposed implementation of Obamacare — from U.S. Sen. Ted Cruz’s 21-hour speech on defunding and repealing the law to Gov. Rick Perry’s decision not to set up a state-run marketplace or expand Medicaid eligibility under the law.

Currently, the majority of federal government operations have shut down because Congress remains deadlocked on passing a budget resolution. President Obama and Senate Democrats refused to accept measures backed by Republicans in the U.S. House that would have delayed the individual insurance mandate in the Affordable Care Act.

Alan Morgan, chief executive officer of the National Rural Health Association, emphasized that delaying some aspects of the law could have negative consequences, particularly for rural health care providers, because they've already endured payment cuts — such as reduced Medicare rates — to finance the new law. If those payment rates aren’t restored, people don’t purchase coverage in the federal marketplace, and states don’t expand Medicaid, health care providers will be facing a three-fold reduction in reimbursements, he said.

“The hope is that rural hospitals and rural clinics will be able to keep their doors open,” he said. By increasing access to health insurance, he said, federal health reform could reduce the financial losses of rural hospitals and clinics and help those facilities remain financially viable. “The pressures put on these rural facilities from the uninsured and the changing health care environment as a whole — these are tough times for rural health care,” he said.

In Texas, state leaders are also pushing for additional regulations on federal navigators, the individuals trained to help people enroll in health plans through the federal marketplace.

Perry directed the Texas Department of Insurance to enact regulations to ensure that navigators were properly trained to protect consumers’ private information. But at an informal meeting held by TDI on Monday, Democrats and health care organizations expressed concerns that the regulations were politically motivated and that the additional regulations could stifle implementation of the law.

Texas continues to have the highest rate of people without health insurance in the nation. One in four Texans — more than 6 million people — lack health coverage, according to 2012 census estimates.

Although more than 1 million children in Texas are uninsured, the majority of uninsured Texans are adults between the ages of 18 and 65. In total, 19.7 million Texans had health coverage during some point in 2012; 14.5 million had private coverage, while 7.3 million were covered by government health insurance.

The Affordable Care Act expands access to health coverage by offering Medicaid coverage to adults at or below 138 percent of the federal poverty threshold, and offering sliding scale tax credits to adults between 100 and 400 percent of the poverty threshold to purchase health plans in the federal marketplace. By expanding health coverage, the law intends to reduce the cost of caring for uninsured people who can’t pay for their health services. In 2010, Texas hospitals and charity clinics provided $17.6 billion in uncompensated services to care for uninsured people. Taxpayers and people with insurance ultimately pick up the tab for uncompensated care.

Although the U.S. Supreme Court deemed the individual health insurance mandate constitutional, it ruled that states did not have to expand Medicaid eligibility to cover poor adults. As a result, Texas chose not to expand Medicaid eligibility. Although the people who would have qualified for Medicaid in Texas are so poor that they are exempt from the insurance mandate, proponents of Obamacare argue that the law will not be as effective at reducing uncompensated care costs.

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Texas Tribune donors or members may be quoted or mentioned in our stories, or may be the subject of them. For a complete list of contributors, click here.